Make the bold choice. This year's HFMA Annual Conference will inspire you to take action, giving you the tools you need to lead change and deliver on the promise of transformation. Focused on improving the business of health care, the conference draws more than 2,500 healthcare leaders from across the nation every year.

MA plans have taken a different approach to value-based insurance design than did earlier VBID models—and only about one-third of enrollees are interested, according to an early analysis.

The VBID expansion is the means through which the Centers for Medicare & Medicaid Services (CMS) will test innovations in the Medicare Advantage (MA) program. A separate Part D model will test whether plans can find ways to help lower Medicare drug spending.

“I think both models are good ideas that hold a lot of potential,” said Adam Finkelstein, JD, counsel with Manatt Health. “The details of each model's implementation really matter, though, and it is hard to gauge the prospects of success without seeing how CMS plans to implement them in
practice.”

The CY20 VBID initiatives will add to the existing VBID program already operated by the Center for Medicare and Medicaid Innovation (CMMI). The MA VBID model—launched in January 2017—aims to cut Medicare spending while enhancing care quality through reduced cost sharing or additional
supplemental benefits for enrollees with select chronic conditions.

The voluntary expansion will be open to MA plans, Regional Preferred Provider Organizations, and all special-needs plans. The CY20 VBID
application period is open through March 1, 2019.

The new VBID models will focus on one or more of the following:

Condition- or socioeconomic-based designs

Rewards and incentives programs

Telehealth networks

Wellness and healthcare planning

As part of telehealth approaches to be tested in the model, MA plans can use telehealth services instead of in-person visits to meet network adequacy requirements. MA plans must ensure that enrollees can still make an in-person visit if they prefer.

“CMS expects that this will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices,” a
CMS fact sheet stated.

Generally, telehealth may comprise up to one-third of the required access to in-network specialists.

The VBID model will be expanded in CY21 to test the Medicare hospice benefit among MA plans.

CMS also extended the performance period of the VBID model by an additional three years, through 2024.

Drug Plan Model

In January 2020, CMMI plans to launch the Part D payment modernization model to test whether incentives can be used in prescription drug plans (PDPs) or MA-PDPs to steer plans, patients, and providers to choose drugs with lower list prices.

Under the voluntary, five-year model, plans will take two-sided risk for CMS’s federal reinsurance subsidy (80 percent of catastrophic-phase liability). Plans in the model can create new rewards and incentives to increase engagement by enrollees and promote better enrollee understanding
of their benefits, out-of-pocket costs, and other drug options.

CMS said the model aims to address overall Part D spending, which almost doubled (to $146.1 billion) from 2010 to 2016—despite a proliferation of generic drug options. CMS’s evaluations blamed the increase on high list prices of new specialty and branded medications for cancer, Hepatitis
C, rheumatoid arthritis, and other conditions.

“However, while payments to Part D plan sponsors to administer the benefit have more than doubled from 2006 to 2017, the portion of the Part D benefit that plan sponsors are liable for managing, termed the direct subsidy, has decreased,” a
CMS fact sheet stated.

After one plan year, CMS will retrospectively create a spending target benchmark that represents the federal reinsurance subsidy (80 percent of Part D catastrophic-phase costs after rebate) that CMS projects would have been paid to participating organizations if they were not
participating in the model.

If a plan’s federal reinsurance subsidy spending is lower than its spending target, then the parent organization will receive performance based-payments based on the total percent saved. If the spending is higher than the benchmark, participating parent organizations will have to repay 10 percent
of the difference.

Plans can use “clinically based drug utilization management techniques that make prescription drugs with lower list price available while also ensuring appropriate beneficiary access,” CMS stated.

A 2018
HealthMine survey of 781 MA beneficiaries found that just 25 percent said their plan offered a digital tool to predict drug costs.

The request for application to join the model for CY20 will be available on the model’s
website, and applications will be accepted through March 1, 2019.

Finkelstein, a former CMMI official, warned that the application time frame could cause problems.

“One thing that strikes me is that it could be that there simply won't be enough time for most plans to pull together an application this spring,” he said in an interview. “If that's the case, I'd expect many potential applicants to skip this cycle and aim for a Jan. 1, 2021, start.”

Early VBID Results

CMS also recently released an
evaluation of the first-year results for the MA VBID program, which targeted enrollees with COPD, congestive heart failure, diabetes, and hypertension. The voluntary program for enrollees provided VBID benefits to 61 percent of the 96,000 eligible beneficiaries. However, most 2017 MA plan data were not complete in
time to include a full impact analysis for this first report, according to CMS.

The analysis found VBID MA plans had no changes in enrollment, which wasn’t surprising since they were not allowed to market their VBID benefits, said Christine Eibner, an author of the analysis and a senior economist at the RAND Corporation. CMS later relaxed those marketing
restrictions.

The analysis also found no difference in Medicare bids by VBID plans. But that finding also was not a surprise to Eibner, she said in an interview, because savings from VBID that would justify lower bids were unlikely in the first year.

The VBID approaches used by the MA plans differed from earlier employer-plan VBID designs, Eibner said. Many earlier VBID models focused on incentivizing better pharmaceutical use, while most MA VBID plans focused on incentivizing care management. For example, enrollees in the MA
plans had their cost sharing reduced when they participated in care management activities.

“Many of the plans see the care management itself as a key component of their VBID intervention,” Eibner said.

However, only 30 percent of patients in plans with a care management approach engaged with the care management program.

“Maybe for the subset that did engage it had more benefits, but that remains to be seen,” Eibner said.

Another difference from earlier VBID plans was the MA plans’ use of rebate checks for out-of-pocket spending, instead of reduced cost sharing, as an enrollee incentive.

The MA VBID model hopes to improve on the employer experience with VBID, which Eibner said improved process-related outcomes (like medication adherence) but had a decidedly mixed record on driving reduced overall spending.

“Potentially, there is more bang for the buck for implementing VBID in Medicare Advantage because people are costlier” than in employer plans, Eibner said.

The VBID model started in seven states and now is in 18 states. The Bipartisan Budget Act of 2018 expanded the model to all states and territories by 2020.

MA plans have taken a different approach to value-based insurance design than did earlier VBID models—and only about one-third of enrollees are interested, according to an early analysis.

The VBID expansion is the means through which the Centers for Medicare & Medicaid Services (CMS) will test innovations in the Medicare Advantage (MA) program. A separate Part D model will test whether plans can find ways to help lower Medicare drug spending.

“I think both models are good ideas that hold a lot of potential,” said Adam Finkelstein, JD, counsel with Manatt Health. “The details of each model's implementation really matter, though, and it is hard to gauge the prospects of success without seeing how CMS plans to implement them in
practice.”

The CY20 VBID initiatives will add to the existing VBID program already operated by the Center for Medicare and Medicaid Innovation (CMMI). The MA VBID model—launched in January 2017—aims to cut Medicare spending while enhancing care quality through reduced cost sharing or additional
supplemental benefits for enrollees with select chronic conditions.

The voluntary expansion will be open to MA plans, Regional Preferred Provider Organizations, and all special-needs plans. The CY20 VBID
application period is open through March 1, 2019.

The new VBID models will focus on one or more of the following:

Condition- or socioeconomic-based designs

Rewards and incentives programs

Telehealth networks

Wellness and healthcare planning

As part of telehealth approaches to be tested in the model, MA plans can use telehealth services instead of in-person visits to meet network adequacy requirements. MA plans must ensure that enrollees can still make an in-person visit if they prefer.

“CMS expects that this will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices,” a
CMS fact sheet stated.

Generally, telehealth may comprise up to one-third of the required access to in-network specialists.

The VBID model will be expanded in CY21 to test the Medicare hospice benefit among MA plans.

CMS also extended the performance period of the VBID model by an additional three years, through 2024.

Drug Plan Model

In January 2020, CMMI plans to launch the Part D payment modernization model to test whether incentives can be used in prescription drug plans (PDPs) or MA-PDPs to steer plans, patients, and providers to choose drugs with lower list prices.

Under the voluntary, five-year model, plans will take two-sided risk for CMS’s federal reinsurance subsidy (80 percent of catastrophic-phase liability). Plans in the model can create new rewards and incentives to increase engagement by enrollees and promote better enrollee understanding
of their benefits, out-of-pocket costs, and other drug options.

CMS said the model aims to address overall Part D spending, which almost doubled (to $146.1 billion) from 2010 to 2016—despite a proliferation of generic drug options. CMS’s evaluations blamed the increase on high list prices of new specialty and branded medications for cancer, Hepatitis
C, rheumatoid arthritis, and other conditions.

“However, while payments to Part D plan sponsors to administer the benefit have more than doubled from 2006 to 2017, the portion of the Part D benefit that plan sponsors are liable for managing, termed the direct subsidy, has decreased,” a
CMS fact sheet stated.

After one plan year, CMS will retrospectively create a spending target benchmark that represents the federal reinsurance subsidy (80 percent of Part D catastrophic-phase costs after rebate) that CMS projects would have been paid to participating organizations if they were not
participating in the model.

If a plan’s federal reinsurance subsidy spending is lower than its spending target, then the parent organization will receive performance based-payments based on the total percent saved. If the spending is higher than the benchmark, participating parent organizations will have to repay 10 percent
of the difference.

Plans can use “clinically based drug utilization management techniques that make prescription drugs with lower list price available while also ensuring appropriate beneficiary access,” CMS stated.

A 2018
HealthMine survey of 781 MA beneficiaries found that just 25 percent said their plan offered a digital tool to predict drug costs.

The request for application to join the model for CY20 will be available on the model’s
website, and applications will be accepted through March 1, 2019.

Finkelstein, a former CMMI official, warned that the application time frame could cause problems.

“One thing that strikes me is that it could be that there simply won't be enough time for most plans to pull together an application this spring,” he said in an interview. “If that's the case, I'd expect many potential applicants to skip this cycle and aim for a Jan. 1, 2021, start.”

Early VBID Results

CMS also recently released an
evaluation of the first-year results for the MA VBID program, which targeted enrollees with COPD, congestive heart failure, diabetes, and hypertension. The voluntary program for enrollees provided VBID benefits to 61 percent of the 96,000 eligible beneficiaries. However, most 2017 MA plan data were not complete in
time to include a full impact analysis for this first report, according to CMS.

The analysis found VBID MA plans had no changes in enrollment, which wasn’t surprising since they were not allowed to market their VBID benefits, said Christine Eibner, an author of the analysis and a senior economist at the RAND Corporation. CMS later relaxed those marketing
restrictions.

The analysis also found no difference in Medicare bids by VBID plans. But that finding also was not a surprise to Eibner, she said in an interview, because savings from VBID that would justify lower bids were unlikely in the first year.

The VBID approaches used by the MA plans differed from earlier employer-plan VBID designs, Eibner said. Many earlier VBID models focused on incentivizing better pharmaceutical use, while most MA VBID plans focused on incentivizing care management. For example, enrollees in the MA
plans had their cost sharing reduced when they participated in care management activities.

“Many of the plans see the care management itself as a key component of their VBID intervention,” Eibner said.

However, only 30 percent of patients in plans with a care management approach engaged with the care management program.

“Maybe for the subset that did engage it had more benefits, but that remains to be seen,” Eibner said.

Another difference from earlier VBID plans was the MA plans’ use of rebate checks for out-of-pocket spending, instead of reduced cost sharing, as an enrollee incentive.

The MA VBID model hopes to improve on the employer experience with VBID, which Eibner said improved process-related outcomes (like medication adherence) but had a decidedly mixed record on driving reduced overall spending.

“Potentially, there is more bang for the buck for implementing VBID in Medicare Advantage because people are costlier” than in employer plans, Eibner said.

The VBID model started in seven states and now is in 18 states. The Bipartisan Budget Act of 2018 expanded the model to all states and territories by 2020.

A senior leader at Grant Thornton LLP HealthCare Advisory Services talks about key ways to lay the groundwork for a shift to cloud-based ERP solutions. Insights stem from a presentation given at the HFMA Large System Controllers Council.

HFMA RESOURCE LIBRARY

Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.

No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.

This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.

This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.

Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.

Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.

To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.

Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.

Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.

Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.

Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.

The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.

Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.

Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.

Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.

Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.

The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.

The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.

Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.

Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.

Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.

Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.

HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.

The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.

Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.

Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?

Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.

This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.

Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.

With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.

Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.